Basic Information
| Provider Information | |||||||||
| NPI: | 1508181488 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPONHALTZ | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 87 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782910087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103589500 | ||||||||
| FaxNumber: | 2103589183 | ||||||||
| Practice Location | |||||||||
| Address1: | 903 W MARTIN ST | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782070903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103583441 | ||||||||
| FaxNumber: | 2103585944 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2010 | ||||||||
| LastUpdateDate: | 06/05/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA06539 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 214265502 | 05 | TX | MEDICAID | 214265503 | 01 | TX | CSHCN | OTHER |